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Lab Manual for UCSF Clinical Laboratories

Lab Manual for SFGH

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Clinical Laboratories Reflexive Ordering

Clinical Laboratories Reflexive Ordering

The UCSF Medical Board recognizes that in some instances it is medically appropriate to perform reflex testing based on an initial laboratory result and in other instances reflex testing should be at the discretion of the ordering practitioner. In accordance with the UCSF Clinical Laboratory OIG Compliance Plan we approve the following reflex testing activity as proposed by the Laboratory Director. (Approved by UCSF EMB 8/25/2009)

TEST ORDER REFLEX ACTION OPTION
BLOOD BANK
Antibody Identification Additional procedures will be performed at an added charge if the routine procedure (ABID) is insufficient. None, always reflexed
Antibody Screen If positive, testing initiated as required to identify the antibody (additional charges apply). None, always reflexed
Direct Coombs Test If polyspecific test is positive, lab will initiate testing to determine if reactivity is due to IgG or Complement on Red cells None, always reflexed
Fetal Bleed Screen If positive, the sample is referred to hematology for Kleihauer-Betke testing to determine the extent of the bleed and to calculate the Rhogam dosage. The Kleihauer-Betke test is billed separately. None, always reflexed
CHEMISTRY
Hemoglobinopathy evaluation If variant hemoglobin is detected by HPLC, hemoglobin electrophoresis is performed to characterize and classify the variant and billed for separately. None, always reflexed
CYTOGENETICS
Aneuvysion FISH If an abnormality is detected the Director will determine the appropriate additional studies to be performed to characterize the abnormality. Additional testing may be omitted if specifically requested when the sample is submitted for cytogenetic analysis.
Chromosome analysis If an abnormality is detected the Director will determine the appropriate additional studies to be performed to characterize the abnormality. Additional studies may be separately billed. Additional testing may be omitted if specifically requested when the sample is submitted for cytogenetic analysis.
Metaphase/Interphase FISH If an abnormality is detected the Director will determine the appropriate additional studies to be performed to characterize the abnormality. Additional testing may be omitted if specifically requested when the sample is submitted for cytogenetic analysis.
Subtelomere FISH If an abnormality is detected the Director will determine the appropriate additional studies to be performed to characterize the abnormality. Additional testing may be omitted if specifically requested when the sample is submitted for cytogenetic analysis.

HEMATOLOGY
Urinalysis Samples submitted with orders for Urine macroscopic only (UA) that are positive for ascorbic acid (Vit. C) and negative for hemoglobin will be evaluated microscopically to rule out the presence of red cells. The UA will be canceled and a Urinalysis with microscopic examination will be ordered and billed (See additional information) None, always reflexed
Urinalysis with Microscopy Note this is a 'negative reflex': If the urine is negative for Protein, Hemoglobin, Leukocyte esterase and Ascorbic acid (Vit. C) the microscopic examination will be cancelled and credited
IMMUNOLOGY
Hep B Surface Ag Confirmatory test is run on all positives and separately billed None, always reflexed
HIV Antibody and Antigen Combination Test HIV-1 Western Blot Confirmatory testing will automatically be performed on all positive samples at an additional charge. None, always reflexed
Lyme Disease Ab Western Blot confirmation is automatically performed on all EIA positive tests. None, always reflexed
RPR (Routine or Prenatal) Yes, if positive a confirmatory test (TPAB) will be performed and billed for separately. APeX allows RPR to be ordered w/out reflex TP-AB
MICROBIOLOGY/VIROLOGY
Bacterial Cultures If bacteria are present that are not considered normal flora, identification and susceptibility testing is performed as appropriate and separately billed. Full ID and susceptibility may be omitted by request
Stool Culture If bacteria are detected that are not normal mixed flora they are automatically identified and susceptibility testing is performed if appropriate. If stool is visibly bloody or the box for 'bloody stool' is indicated on the order, media to detect E. coli 0157:H7 will automatically be set up. If E. coli O157 is detected the isolate is automatically referred to SFPH to determine if the strain is a toxin producer. Full ID and/or susceptibility testing may be omitted upon request when sample is submitted for testing. E. coli reflex: None, always reflexed
Cryptococcal Antigen If positive, specimen is titered at a separate charge. None, always reflexed
First positive sputum smear for Acid-Fast-Bacilli (AFB) Mycobacterium tuberculosis complex PCR will be performed automatically. Automatic reflex to State Public Health laboratory for Molecular probe testing for M. tuberculosis. Test can be ordered w/out the reflex. None, always reflexed
Clostridium difficile Antigen Cell culture and neutralization for toxin will be performed if antigen is positive and billed separately. None, always reflexed
Staph aureus Culture Susceptibility testing is performed if Staphylococcus aureus is isolated. None, always reflexed
MOLECULAR DIGNOSTCS
C9ORF72 Repeat Expansion Positive expansions are reflexed to a Southern blot based-assay that will determine the approximate ranges of the expanded repeat. None, always reflexed
Cystic Fibrosis, PCR for common mutations 5|7|9T Polymorphism test will be performed on all samples with R117H mutations and separately billed. None, always reflexed
PML-RARA PCR, Qualitative If a translocation is detected the quantitative assay (PMLQ) will be performed at an additional charge. None, always reflexed
PML-RARA PCR, Quantitative If the PML-RARA Quantitative test (PMLQNT) is ordered and the patient has not had a prior qualitative test (PMLR) performed, the qualitative analysis will be performed first to identify if a translocation is present and what type it is prior to quantitative analysis. The qualitative testing will be performed at an additional charge. None, always reflexed
NCPL
HIV, Rapid Antibody Screen If positive a confirmatory Western Blot will be performed and separately billed. None, always reflexed
SENDOUTS
Bartonella species Antibodies Bartonella Species Antibody (IgG, IgM): If Bartonella henselae and B.Quintana IgG and IgM Screens are positive, titers are performed at an additional charge. Reflex testing will be manually billed when results are reported by Quest-Nichols Diagnostic Lab. None, always reflexed
Brucella antibodies (IgG, IgM) If Brucella IgM result is ≥ 1.10, then Brucella Antibody, Agglutination will be performed at an additional charge None, always reflexed
Echinococcus granulosa Antibody (IgG) Positive samples will be automatically titered with a separate charge None, always reflexed
Hantavirus Antibodies (IgG & IgM) If Hantavirus IgG is > 1.10 and Hantavirus IgM is >1.10 then Sin Nombre Virus IgG Comfirmation will be performed at an additional charge. None, always reflexed
Hereditary Spherocytosis Evaluation If indicated based on osmotic lysis results flow cytometry is performed as an additional step in the evaluation and charged separately None, always reflexed
Islet Cell Antibody Yes, if positive titer will be performed at an additional charge None, always reflexed
JC virus Antibody If the JCV Antibody result is, "INDETERMINATE", STRATIFY JCV™ Antibody Inhibition Assay will be performed at an additional charge (CPT code(s): 86711) None, always reflexed
Leptospira Antibody If positive, titering is performed and charged separately. None, always reflexed
Pain Management Panel Positive results for Amphetamine, Opiates and Oxycodone will automatically reflex to confirmatory testing. None, always reflexed
Porphyrins Evaluation, RBC For samples with porphyrin ≥ 80p µg/dL fractionation is automatically performed at an additional charge. None, always reflexed
Rocky Mountain Spotted Fever Antibodies (IgG & IgM) If screen is positive the titers will be performed at an additional charge. None, always reflexed
von Willebrand Factor Cleaving Protease Yes, If the test for Protease Inhibitor is required, it will be ordered and billed at an additional charge. None, always reflexed
West Nile Virus Antibodies, Serum (IgG & IgM) Samples with reactive IgM are rerun in a modified test to rule out nonspecific reactions. None, always reflexed
West Nile Virus Antibody, CSF CSF samples with reactive IgM are rerun in a modified test to rule out nonspecific reactions. None, always reflexed

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